Making General Surgery Available to All in Rural North Dakota

By Brenda Haugen on
March 15, 2018July 20, 2018

Mary Aaland, MD

Thirty or 40 years ago, most rural hospitals performed
general surgeries. They delivered babies, repaired
hernias, and removed gallbladders. It also was common at
that time for a patient to spend seven days in the
hospital after a procedure.

Today, 65 to 70 percent of general surgery is done on an
outpatient basis.

Most of these outpatient surgeries could be done at rural
hospitals. "We need to reestablish surgery as part of the
healthcare team," Aaland said.

Aaland was hired to help develop the
Rural Surgery Support Program (RSSP), which was
started in July 2014 by the Department of Surgery at the
UND SMHS. Since its inception, RSSP has provided coverage
for rural surgeons in North Dakota who need time off.
Rural hospitals appreciate the opportunity to have
coverage by a surgeon who is known, licensed, and
credentialed in the state.

RSSP also has helped recruit surgeons in rural
communities.

"There is a drastic shortage of physicians in this
state," Aaland said, adding that there's an even greater
shortage of general surgeons.

There are many reasons why it's difficult to recruit and
retain rural surgeons. For one, it's hard to find someone
to cover for a rural surgeon when he or she wants to take
a vacation or attend educational programs or trainings.
Many critical access hospitals have just one surgeon.
That surgeon may be on call 24 hours a day, seven days a
week for long periods of time, which can lead to burnout.

RSSP can help. The support provided by RSSP is tailored
to the individual needs, personalities, and assets of the
communities. "Every community is different," Aaland said.

Mary Aaland (center) teaching a community class.

Aaland doesn't come into a rural hospital and dictate to
the staff what they need to do. Instead, she listens and
learns - about the hospital and the community. She said
the hospitals and the communities they serve know what
they need, and she tries to provide guidance to help meet
those needs.

When RSSP first started, Aaland visited all
rural hospitals in North Dakota to explain the
program's mission and its potential benefits. Ever since
those initial meetings, response to the program has been
incredibly positive.

Aaland wants to see high-tech, high-quality general
surgeries done at local rural hospitals, so patients
don't have to travel 100 to 150 miles for care. Her goal
is that, as a team is built, almost 65 percent of the
general surgical needs will be able to be met locally.
She doesn't want anyone to have to travel more than 50
miles for general surgeries. In less than three years,
she's almost achieved that goal.

Having people travel long distances for general surgeries
has financial and emotional costs. What Aaland is trying
to do is manage healthcare dollars wisely. For example, a
wheelchair-bound nursing home resident needed an
outpatient procedure that Aaland could perform locally.
Not only did this save the cost - both monetarily and
emotionally - of transporting this patient by ambulance
to a hospital many miles away, it allowed the patient the
comfort of being close to home and allowed the patient's
family to be there for support as well.

What is the best thing for the patient? That is what
guides me.

"What is the best thing for the patient?" she asked.
"That is what guides me."

Part of surgical care is prevention, including cancer
prevention. According to Aaland, colonoscopies,
endoscopies, and "lumps and bumps" are things that can be
handled readily by rural surgical teams. Aaland recently
did four colonoscopies at one facility, and she believes
two probably wouldn't have had the procedure done if they
had been required to travel to the nearest city to do it.
Aaland also can work with city doctors and arrange to do
pre-ops locally and save patients a trip.

Right now, Aaland is playing a dual role. She's doing
surgeries in rural hospitals herself while trying to
attract other surgeons to these areas. Her goal is to
recruit enough surgeons that she puts herself out of
business - and she's on her way. She recently hired two
surgeons who are helping in Jamestown and Devils Lake.
She's also building surgical teams, including equipment
and personnel, at McKenzie County
Hospital in Watford City. In addition, she helps out
at a number of others rural hospitals in North Dakota,
including West River
Health Services in Hettinger, Cavalier County
Memorial Hospital in Langdon, and Heart of America Medical
Center in Rugby. She'd like to help other communities
as well, she said, but she is still working out the
details.

Aaland keeps up quite a pace working with the RSSP. In
September, for example, she was only home three 24-hour
periods. But she can see that she's making a difference
and that helps keep her going. Along with her work
setting up local surgical teams in rural hospitals across
the state, a couple of other surgeons have followed her
lead and begun working in rural areas of the state as
well.

Being copied is good.

"Being copied is good," she said.

A native of Northwood, North Dakota, and a 1982 graduate
of the UND SMHS, Aaland is certified by the American
Board of Surgery in surgical critical care and general
surgery. After owning and operating a private medical
practice in Fort Wayne, Indiana, for more than two
decades, Aaland wanted to give back to her home state,
and RSSP has proved to be the perfect avenue to do so.

Even when she's not working in rural hospitals, Aaland is
spending time in those communities, making sure she's
visible. She enjoys walking, and a friendly "hello"
during a stroll can go a long way in a small town.

And what kind of feedback does she get from the hospitals
and patients with whom she works? "The feedback is I
still have a job," she said with a chuckle.

Brenda Haugen
is the communications specialist at the Center for Rural Health at the University of North Dakota (UND) School of Medicine & Health Sciences in Grand Forks.